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Who is Responsible for the Opioid Epidemic?

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deaths_1999-2011_heroin

The answer to that question is of course multifaceted. But one part of the answer is, not surprisingly, the drug companies who profit handsomely by flooding the nation with opioids.

Drug wholesalers sent 780 million hydrocodone and oxycodone pills into West Virginia over six years, according to an investigation by the Charleston Gazette-Mail.

Meanwhile, 1,728 West Virginians died from overdoses of these two powerful painkillers.

780 million pills. Is that all? And only 1728 deaths? Well, so much potential profit in getting that up to 2000! And the whole thing is just super sketchy:

1. What was the biggest surprise for you?

Drug wholesalers shipped enough painkillers to provide 433 pills for every man, woman and child in the state, Eyre said. And in parts of the southern West Virginia coalfields, the numbers were even higher.

“I was surprised that some of the smallest pharmacies had some of the biggest numbers,” Eyre said. For example, nearly 9 million hydrocodone pills to one pharmacy in Kermit, W.Va., population 392.

“In Oceana, one pharmacy received 600,000 – 700,000 oxycodone pills a year. The Rite Aid six blocks away gets 6,000.”

2. Did the drug wholesalers do anything illegal?

“They have a legal obligation to report these suspicious orders to the (federal) Drug Enforcement Agency,” and to the state Board of Pharmacy, Eyre said.

For years, none of them did. But after a lawsuit was filed by former state Attorney General Darrell McGraw, some wholesalers began to send suspicious order reports to the Board of Pharmacy.

3. What did the Board of Pharmacy do with those reports of suspicious orders from the drug wholesalers?

They put them in a box, Eyre said. They did not tell law enforcement or even tally the information on a computer.

Eyre asked the board’s director about this: “He said the law does not prescribe what they’re supposed to do with the suspicious report, only that they’re supposed to be filed.”

Now, the board is considering sharing these with the State Police or Attorney General.

What could go wrong with a system as well-regulated as this!

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  • kped

    Those numbers are just mind numbing. 9 million pills for a town of less than 400 people. Who are the doctors prescribing this?

    You’d need the doctors, pharmacies and drug makers all in on this. It’s horrifying.

    • efgoldman

      9 million pills for a town of less than 400 people. Who are the doctors prescribing this?

      I doubt that it’s just residents of that one town. I expect the pharmacy is pretty well known ’round the holler.
      Some media organization or other tracks one of these places down every once in a while, and a doctor gets indicted and the pharmacy closes. CBS has been on it periodically.

      • postmodulator

        It was a specific pharmacy drawing addicts from hundreds of miles away:

        http://www.salon.com/2012/04/11/americas_pill_popping_capital/

        Agents who raided the Kermit store said cash drawers were so stuffed they couldn’t close.

        • ThrottleJockey

          Addicts and dealers alike no doubt.

          • Ghostship

            So what? If people want to get high just let them. Then doctors might not feel the urge to write so many prescriptions to get their patients hooked since their patients could freely buy generic opioids over the counter. The added advantage would be that the United States would be able to satisfy the increased demand for raw heroin by buying it off Afghan farmers so increasing the survival chances of the current government.

            • So what?

              Oh, right…people getting addicted and dying. A minor detail to some, no doubt.

              • Ghostship

                people getting addicted and dying

                The dying doesn’t follow the addiction, it’s normally for other reasons.

                • ThrottleJockey

                  You haven’t been reading the data on the current epidemic very well. Take a look at the fastest growing cause of death for seniors.

    • ThrottleJockey

      You’d need the doctors, pharmacies and drug makers all in on this. It’s horrifying.

      And the addicts too. You’d need their cooperation. Its not like they strap you into the machine and force it in intravenously.

      • jharp

        People can end up addicted for a myriad of reasons.

        • ThrottleJockey

          I’m actually assuming the best of intentions on the part of the users. A lot, probably most, of people get addicted to painkillers following significant injuries. After some period of time, perhaps months perhaps years, people eventually realize they’re addicted. With recognition comes responsibility.

      • Dennis Orphen

        Its not like they strap you into the machine and force it in intravenously.

        You can have that done, but it costs extra.

      • DrDick

        Without the others, there are no addicts. I know it is your favorite game, but do not blame the victims or you are just an asshole.

        • ThrottleJockey

          Without the addict there’s no addict.

          Do you say this about alcoholics too? It’s the fault of brewers, vintners, and distillers? What about all the 40 and 30 somethings addicted to cigarettes who know for a fact it’s deadly? It’s Marlboro’s fault.

          You’d have it so that people are mindless robots doing whatever society programs them to do with no individual agency at all.

          • efgoldman

            Without the addict there’s no addict.

            How wonderful for you that you’re perfect, so you can be so judgemental.
            Of course that’s been your stance on pretty much anything for as long as I’ve seen you here.

            • ThrottleJockey

              I’ve never described being perfect. Much the opposite I have plenty of addictions and I’m simply lucky that none of them are illegal. (Though motorcycle riding can be unhealthy). One of the reasons I refrain from gambling is because I think I’d be very addicted to it.

              But if you know anyone with a substance abuse problem then you know that the first obstacle is to admit that you have a problem. Blaming society for a problem is more or less a way for the abuser to escape ownership of the problem. And when non addicts blame society you’re merely enabling the addict.

          • The thing, about addiction…the very real thing about it…is that even though you know that what you’re taking is deadly, it is very, very, hard to stop. This is why getting people addicted is a problem- and, to the extent that companies and doctors do that…and, to the extent that beer companies and cigarette companies do the same for the sake of profit, they are responsible.

            You’d have it so that people are mindless robots doing whatever society programs them to do with no individual agency at all.

            Your analysis of drug addiction is as simple-minded as your analysis of electoral politics. Again, you trade in false dichotomies. Either we make the addict primarily responsible for their addiction, basically letting everyone else off the hook, or people who get addicted are “mindless robots doing whatever society programs them to do with no individual agency at all”.

            The notion that multiple actors bear responsibility, that we can admit that individual responsibility is not absolute, and we can acknowledge that factors like addiction can seriously impinge on an individual’s ability to act as a rational autonomous agent without completely denying such individuals agency, is not allowed to enter into the picture.

            • ThrottleJockey

              Not at all Paul. I operate under the assumption (based on experience) that most people became addicted after doctors put them on painkillers too long. So in my opinion doctors bear primary responsibility. They have a moral obligation to the patient to do no harm. Over prescribing is harm.

              But at some point when the patient recognizes their addiction they have an obligation irrespective of how hard it is to overcome or what their doctors prescribed. I’ve known tea totalers to get addicted through no fault of their own. That doesn’t relieve them of accountability.

              Know any alcoholics? You cut them any slack when they drive drunk? What about when they come home and beat the wife and kids? Or pull a gun on the neighbor in a drunken rage? If you do then you’re wrong for it and if you don’t then you should be having the same response to addicts. Substance abuse is substance abuse.

              Shit sometimes you have to turn down medicine because of the risk. I never take the full bottle of pain pills. I know it’s too easy to get addicted. Right now my primary worry with my father is that he’s developing an addiction to opiates because of his surgery this summer. I’m counting the pills he takes each week. Because I don’t want him to get accidentally addicted.

    • Yankee

      I got to wonder how many of those pills aren’t finding their way back to the Big City.

    • Dr. Ronnie James, DO

      I don’t know about WV, but FL and IIRC CA found that occupational health centers were giving out similarly staggering #s of scripts for opioids through worker’s comp claims.

      Similarly, when I worked in NYC gov’t on this, everyone was surprised to see the opioid OD rate was vastly higher in Staten Island – with all its cops, firemen and Republicans – than anywhere else. It’s a high for “respectable” people i guess.

      • ThrottleJockey

        Rush Limbaugh Exhibit 1 here.

    • Captain C

      My rough calculation says that this is over 4100 pills per day, enough for 4 pills per day for 1,000 people, or 2 per day for 2,000, for six years.

      Mind you, I don’t know how many oxy pills an addict would eat, but given how strong I’ve heard the stuff is, I can’t imagine it would be much more than four, even with a heavy addict.

  • efgoldman

    Jeebus Fucking Christ on a cross of heroin……

    Didn’t I see (maybe here, maybe yesterday) that in legal medical marijuana states, opioid use and deaths are sharply down?

    • I’m sure putting an end to that kind of thing will be high on Attorney General Sessions’s list of priorities!!!

      • njorl

        Filthy hippie drugs like marijuana have no place cutting into reputable businesses like the oxycontin trade.

        • Ghostship

          To bloddy right and so what if you have drug reps. stood outside infant schools, doling out the oxycontin. It’s the capitalist way.

  • Gareth

    Do you have the post about overly aggressive enforcement of drug laws leaving thousands of people in agony already written?

    • njorl

      Reasonable oversight is possible without being overly restrictive toward legitimate use. We’re not children. If we choose to regulate the drugs involved properly, we can do so.

      • I’m still waiting for we as a society to pull that one off.

        • tsam

          Weed here in Washington and in Colorado has worked out very nicely. I think the day is coming–but we’ll always have our weird obsessions with particular drugs and be all shruggy about the more dangerous ones. Alcohol can be a particularly devastating drug, but is very ingrained in our culture. Weed is pretty dang harmless for a mind-altering substance, and there is still a hilariously stupid amount of stigma around it, thought that’s evaporating pretty quickly, I think.

          • humanoid.panda

            I suspect that’s its much easier to reasonably regulate marijuana than heroin.

            • tsam

              Most likely. Nobody overdoses on marijuana either, so it doesn’t need the most stringent regulations.

            • Portugal seems to be doing reasonably well with its decriminalisation of all recreational drugs, though I haven’t looked up stories about it in a few years. Regardless, overdose deaths and new infections of HIV/hepatitis/etc. were substantially down, IIRC.

          • BiloSagdiyev

            Evaporating? Or going up in smoke?

      • efgoldman

        We’re not children.

        Imputes facts not in evidence, yer honor.
        Especially when you look at the Kongressional Krazy Kkkaukus.

    • Dr. Ronnie James, DO

      Thank you – few things make me crazier than this argument. Opioids were *never* meant as a long-term management for pain, and there are literally dozens of proven effective non-narcotic approaches to pain. Long-term opioids usually imply patients are getting lazy/bad pain management. There are cases that call for them, but they’re so rare no competent provider should really get cracked down on for them.

  • Q. Who is Responsible for the Opioid Epidemic?

    1. Purdue Pharma
    2. Abbott Labs
    3. Johnson & Johnson
    4. Pfizer
    5. Novartis
    6. Covidien
    7. Watson Pharmaceuticals
    8. Endo Pharmaceuticals
    9. All of the above

    Answer is 9

    • JustRuss

      Maybe it’s time for a War on Drug Companies. I’ll consider enlisting if I can fly an A-10.

      • ThrottleJockey

        That’s a bad ass plane!

      • Colin Day

        Do you know how to fly an A-10? Of course, even if you can’t, you can still do some damage by crashing it into the target.

    • Origami Isopod

      I suspect that anti-marijuana laws have played a role in this too.

      • tsam

        A less direct one maybe, but no doubt they’ve contributed.

    • ThrottleJockey

      You left out doctors, dealers and users. Of all these I blame the doctors most and the users themselves second most.

      Doctors over prescribed painkillers. I have one relative who I’ve been the caregiver for. Doctor put her on painkillers and never told her it was highly addictive nor told her or the family the symptoms of addiction (which closely mimic the flu). Unfortunately people facing symptoms take more pills thinking that the pills will help “cure” their flu not realizing the flu is actually opiate withdrawal. And of course the pills do cure “the flu”…until the user runs out of their stash. Then they get the flu again. It may take users months or even years before they figure out they’re addicted. If doctors prescribe these things they have an ethical obligation to ensure they’re not abused.

      • dl

        doctors high on the list. any halfway thoughtful doctor saw this coming years ago.

        • ThrottleJockey

          If there’s anything I’ve realized it’s that a lot of doctors ain’t that thoughtful.

          • BiloSagdiyev

            Not helping is that the doctors were being told the newfangled pills were _not_ addictive when they came out. Also, something funky with the duration of the effectiveness vs. the prescribed time between pills helped set the hook.

            (I’ll look for a link later..)

            • BiloSagdiyev
            • Hogan

              You mean that nice pharma rep who took me out for a golf outing, dinner and a strip club visit lied to me? INCONCEIVABLE!

      • Murc

        Doctors over prescribed painkillers.

        Except, of course, when they underprescribe them.

        I’d rather have the former than the latter. Yes, I have a personal stake in this; I have family members who have been unable to get the pain management they desperately needed because their doctors didn’t want to be seen as pill-pushers.

        • ThrottleJockey

          Yes you’ve written pretty eloquently about this. There’s a line somewhere for “most” people. We often struggle with this line.

          There are significant physical risks–even those short of death–to over prescribing. There was a time as a caregiver after I recognized that my loved one was addicted and before I started actively intervening. I recognized there was an addiction but the level of addiction presented only moderate risk. It wasn’t until the addiction presented substantial physical risk that I intervened.

          That decision of mine is debatable however. It’s entirely possible and maybe likely that I waited too long. This is my way of saying that it’s a judgement call. Judgement calls are hard work for bureaucracies…Anyone whose ever attempted “an intervention” knows that they’re emotional Hell. Fuck me that shit is hard. I’d just as soon as cut off my arm.

      • Connecticut Yankee

        Doctors are, if anything, even worse with benzodiazepines. They prescribe them much more freely than opiates, often on an as needed basis and as a first . Not only do they not mention how rapidly dependence can develop or describe the withdrawal syndrome, they don’t even seem to know about it!

    • DrDick

      More reasons why profits should never be allowed anywhere near the healthcare system.

      • BiloSagdiyev

        As some much wiser blogocommenter said a few years ago, maybe at Sadlyno: when you put vampires in charge of the bloodbank don’t be surprised when you come up a few pints short every day.

  • tsam

    Opioids have been a struggle for me all through my adulthood. I’m one of the lucky people not willing to track down sources for them–otherwise I’d be in dire straits or dead by now.

    It’s hard to describe what getting off of them is like, but it’s NOT fun.

    • postmodulator

      I sort of hit the lottery there. I’ve tried all the drugs there are and can take or leave any of them — except nicotine and caffeine.

      • tsam

        Any opiate for me is high danger. Nicotine and caffeine are vices, and I do enjoy alcohol but have no trouble controlling it. Can’t use marijuana because it makes me turn green and throw up (WTF?). So it’s cocaine and alcohol for me.

        • efgoldman

          Can’t use marijuana because it makes me turn green and throw up

          Based on your most recent avatar, not hulk smash?

          • tsam

            That’s Hulk with KITTIES. Kittens and puppies hath charms which sooth the smashy beast, no?

        • kped

          …maybe you should lay off the coke too…just seems like playing with fire.

          • tsam

            I have. It’s a once or twice a year thing, and it’s not even as much fun as it used to be. Honestly, I’m trying to put together a reality where I interact with other humans without performance enhancing drugs and stop beating my own dumb ass up for not being a perfect person. I’m getting better at it.

            • postmodulator

              I have a friend, totally not me, who is convinced that the cocaine available to non-rich people these days is so stepped-on and weak compared the cocaine of the 70s that it is basically not worth the bother. My friend even found some reporting backing him up.

              • Sentient AI from the Future

                I’ve sometimes wondered what the economics of retail cocaine would need to be like in order to make extraction-for-resale-at-higher-purity viable. Seems like that would actually be good fodder for an econ lecture.

                • Dennis Orphen

                  Not good, trust me.

            • BiloSagdiyev

              Don’t bear yourself up, tsam. You always have us here to do that for you.

      • DrDick

        Pretty much the same here, except I kicked nicotine 20 years ago (after smoking 2-3 packs a day for 30 years). I have seen the struggles people addicted to opiates go through and it is not pretty.

    • ThrottleJockey

      I’m sorry to hear that brotha. I’ve had to care for loved ones who faced your struggle. The eye opener for me was that the withdrawal was quite bad but didn’t remotely resemble what you see in the movies/TV. Did TV accurately depict (out of control shaking, sweating, vomiting) your withdrawal symptoms? So it took about a year before I realized my relative was addicted.

      • BiloSagdiyev
      • tsam

        I didn’t get to that point. Luckily my doctor caught it and cut me off. But it was about a month of itching, severe fatigue, emotional turbulence…I’m fine now

    • Dennis Orphen

      Have you ever read Poppies by Eric Detzer? I highly recommend it. True story, takes place in Western Washington.

  • ScottRS

    According to Sen. Bill Cassidy (R-LA), the reason is Obamacare.

    http://www.huffingtonpost.com/entry/bill-cassidy-opiod-obamacare_us_58507801e4b0ee009eb43f67

    • efgoldman

      According to Sen. Bill Cassidy (R-LA), the reason is Obamacare.

      Of course it is. Everything is.
      Pearl Harbor? Check.
      1938 Hurricane? Check.
      Losing China? Check.
      Blizzard of ’78? Check.

      • tsam

        Pompeii–is there ANYTHING OBAMA HASN’T FUCKED UP?

        • (((Malaclypse)))

          OBAMA CANCELED FIREFLY. HE CAN’T TAKE THESE SKIES FROM ME!

          • Schadenboner

            I used to consider myself a Democrat, but thanks to Serenity Valley, I’m outraged by Chappaquiddick!

      • Captain C

        Don’t forget the fall of Constantinople, the Mongol invasion of China, the depredations of the Sea Peoples, and the Permian extinction. Probably the collision between the Earth and Theia which formed the moon, too.

        • tsam

          Atlantis. We haven’t even found it yet! DAMN YOU OBAMA. DAMN YOU TO HELL

  • dogboy

    The LA Times has done a fine series this year about opioids

    Purdue did not shut off the supply of highly addictive OxyContin and did not tell authorities what it knew about Lake Medical until several years later when the clinic was out of business and its leaders indicted.

    By that time, 1.1 million pills had spilled into the hands of Armenian mobsters, the Crips gang and other criminals.

    http://www.latimes.com/projects/la-me-oxycontin-part2/

    • Breadbaker

      Thanks, Obama

  • njorl

    It looks like prescription opiate use displaced some cocaine use just as the financial crisis started.

    • postmodulator

      Boy, that’s a bit on the nose, isn’t it?

      • Origami Isopod

        I see what you did there.

        • tsam

          HA! That went right over my head. Guess I picked the wrong week to start sniffing glue.

    • DrDick

      It has also displaced meth in a lot of rural areas.

      • efgoldman

        It has also displaced meth in a lot of rural areas.

        It’s safer (a bottle of oxy can’t blow up and burn your trailer down), more quality controlled (gummint makes it so), cheaper, easier to buy and sell, and at least sometimes (in the very first transaction) legal.

    • Lurking Canadian

      I would imagine (never having tried either) that oxy is less fun than Coke to snort out of some hooker’s butt crack.

  • Shalimar

    Since they didn’t see anything wrong with what was happening, everyone on the Board of Pharmacy should have to take 433 hydrocodone pills at once and see what happens. Maybe the Board members who replace them will give a damn about their communities.

    • Dr. Ronnie James, DO

      Most state boards are vastly underfunded. Please keep this in mind as we discuss how wonderful “devolving health reform to the states” will be.

      • Judas Peckerwood

        What did the Board of Pharmacy do with those reports of suspicious orders from the drug wholesalers?

        They put them in a box, Eyre said. They did not tell law enforcement or even tally the information on a computer.

        Eyre asked the board’s director about this: “He said the law does not prescribe what they’re supposed to do with the suspicious report, only that they’re supposed to be filed.

        That sounds a lot less like “underfunded” than it does “homicidally corrupt”.

        • Dr. Ronnie James, DO

          Agreed. But in my experience state boards (WV aside) tend to be more towards the former.

  • Nang Mai

    There are numerous factors. One is that the synthetic drugs created in labs are wildly more potent than natural opiates. Fentanyl is 50 to 100 times more potent than morphine, for example so users have a hard time determining safe dosages if the opiate wasn’t prescribed. Natural opiates are safer but hard to come by because laws make plant cultivation difficult. The result: a world wide shortage inviting organized crime involvement resulting in a very bad situation for users.

    Another factor: The climate of shame around opiate use contributes to deaths. In Vancouver when a legal injection site (complete with medical and other resources) opened deaths went down.

    But mostly … if this economic system was really working would we be seeing a rise in suicides and drug overdoses? I see a lot of desperate people trying to escape. Opiate use tends to cluster in lower SES areas.

    • DrDick

      The UN would beg to differ about the supply of natural opiates (opium production is way up), in part thanks to our Afghan adventure.

      • In context, I took Nang Mai to be referring to “natural opiates” produced nearby the (American) consumer; clearly Afghan (etc.) opium is too attractive as a raw material for large-scale, international-cartel processing to expect much (if any) of it to reach local US markets at affordable prices, but if it were safe(r) to grow opium poppies (etc.) in the US that opium might be affordable (and “natural”!).

        • Sentient AI from the Future

          i dont know much about poppy cultivation, but my impression is that you need an awful lot of area (and consequently, labor) to support anything like the sort of habits I’ve heard of patients having (one particularly problematic patient anecdotally was taking a full gram of morphine equivalents per day).

          regarding poppy cultivation, there are, worldwide, only two (iirc) legally designated areas for pharmaceutical-destined production. neither is in afghanistan or the broader golden triangle.

          • Breadbaker

            One is in Tasmania. When we were there four years ago, we visited a sheep farm that was also an opium farm. There are serious electric fences around the opium (which was in bloom when we were there) but every year someone sneaks in, takes some, and dies. The strains they grow legally and commercially to create morphine are not your mother’s poppies; they are incredibly concentrated and, unless processed as intended, pretty much fatal to ingest.

        • Nang Mai

          The whole system is broken by stupid laws that unintentionally (?) favour illegal markets and big pharmaceutical companies. Poppy production is up but there is a serious shortage of legal pain meds for most people in the world. Last I heard, the US uses about 80% of the supply meaning millions of people with serious burns, cancer and other serious illnesses go without.

          Legal cultivation of poppies would eliminate the organized crime problem. If organized, more opium could then be directed for medical use. A bigger supply of naturally derived opium might provide a disincentive for big pharma’s synthetic/deadly tinkering.

          • DrDick

            The point of the “tinkering” is twofold. First it is to increase more potent and effective painkillers. The second is to produce a proprietary compound over which the company has a monopoly. Only the latter is actively evil. The problems with the pharmaceutical industry, as with all of capitalism, is the relentless pursuit of ever greater profits.

        • DrDick

          All of the heroin in the US has always come from opium grown in SW Asia (mostly Turkey and Afghanistan), SE Asia, or Mexico. The explosion of heroin chic in the 1990s was fed by the importation of high quality China White heroin from SE Asia.

  • Rob in CT

    I’d like to think we can manage to regulate things in a more intelligent manner (including simply buying the poppy crop from the Afghans for use in making legal, properly dosed drugs) such that folks can get opiates when needed but are not left on them indefinitely, which seems to be a disaster.

    But I’d like to think a lot of things.

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